Clinical Management & Presentation of Addiction Tutorial Flashcards
In the alcohol misuse case study video, what are the main takeaway points of her situation / addiction?
Miss Brown Case Study:
14 bottles a week
Drinks before bed, after she wakes up, in her breaks and lunches
Sleep is poor
Most money spent on alcohol
Stopping = withdrawal shakes and effects
Coping mechanism to deal with daily stress
Not too worried about her addiction
Roughly how many units a week does Miss Brown drink?
What is Miss Brown’s pattern of use?
137 units
Addiction - coping mechanism for stress
What are features of Miss Brown’s dependency?
CAGE - cut down, angry, guilty, eye opener Friends criticise drinking Withdrawal symptoms - hot, sweaty, retching, abdominal pain Poor sleep Tremors Neglects personal relationships No pass time / hobbies Loss of control - always finishes bottle
What did Miss Brown’s Mental State Examination show?
Appearance and Behaviour Speech Mood Thoughts Perception Cognition Insight
Appearance and Behaviour - nil abnormal movements, casual clothing, good eye contact and rapport, slightly defensive
Speech - normal RRT, nil thought disorder
Mood - irritable
Thoughts - nil delusions / obsessions / overvalued ideas, in denial of alcohol intake
Perception - nil hallucinations
Cognition - seemed orientated TPP
Insight - full insight
What are some aspects of an assessment specific to alcohol?
History
Examination
Investigation
History:
Alcohol-related seizures, delirium, alcohol psychosis, haematemesis (vomiting blood), melaena (dark sticky faeces with partially digested blood)
Examination:
Jaundice, anaemia, clubbing, cyanosis, oedema, ascites, lymphadenopathy, DVT
Investigations: Fibro scan / Ultrasound Bloods (LFT, GGT, Lipids, U&E, amylase) Breathalyser Urine Drug Screen
What are alcohol assessment tools?
CAGE screening
Alcohol use disorders identification test (AUDIT)
What are the physical effects of alcohol?
Immediate effects
Long-term effects
Immediate: Impaired reaction time, judgement, co-ordination Less acute vision Nausea, vomiting Flushed, heat loss Reduced sexual functioning
Long-term:
Destroyed brain cells / reduced brain matter - impaired memory
Weakened cardiac muscle, high BP, irregular heartbeat
Increased risk of breast cancer and cancers of the digestive system
Weakened immune system
Reduced fertility
Osteoporosis
Nutrition deficiencies
What are the symptoms of alcohol withdrawal?
Why is alcohol withdrawal worse than opiate withdrawal?
Onset from 6 hours, worsens over time - minor withdrawal symptoms, alcoholic hallucinosis, withdrawal seizures and eventually delirium tremens (DT is a late sign - a medical emergency)
Seizures can occur, alcohol withdrawal can kill you, opiate withdrawal much less likely to do the same
What are some medications for alcohol abstince and redox regimes?
Benzodiazepines
Chlordiazepoxide (librium)
In the drug use case study video, what are the main takeaway points of his situation / misuse?
Mr Steven Case Study:
Started injecting about a year ago Currently 3x a day Used to use clean needles, now they share Stopping = withdrawal symptoms e.g. shivers, nausea Problems finding a good vein Has had abscess Had a minor case of jaundice Lack of concentration Unemployed, steals to fund heroine use Wants to get off heroine
What are the features of Mr Steven’s heroine dependency?
Uncaring about hygiene Withdrawal symptoms - feeling sick, shivers, gooseflesh Injecting often - 3x /day Cannot hold down a job Stealing to fund his habits Neglects personal relationships Distressed if cannot get heroin Cravings and loss of control for need of heroin
What did Mr Steven’s Mental State Examination show?
Appearance and Behaviour Speech Mood Thoughts Perception Cognition Insight
Appearance and Behaviour - nil abnormal movements, dressed in tracksuit, reasonable rapport, looks downcast, collapsed veins (described), restless
Speech - normal RRT, nil thought disorder, softly spoken
Mood - low
Thoughts - nil delusions / obsessions / overvalued ideas, preoccupied with seeking drug
Perception - nil hallucinations
Cognition - not formally tested, orientated TPP
Insight - full insight
What are common symptoms of opiate withdrawal?
Tachycardia Sweating Restlessness Dilated pupils Bone aches Runny nose GI upset Tremor Yawning Anxiety/Irritability Gooseflesh skin
How does the ICD-10 define Dependence Syndrome?
What is the criteria?
3 or more of the following in the past year:
- Compulsion to take a substance
- Loss of control of substance-taking behaviour i.e. onset, termination, or levels of use
- Withdrawal symptoms
- Tolerance (ie. need to take more of the substance to get the same effect)
- Progressive neglect of alternative interests
- Persisting with substance use despite harmful consequences
How does the ICD-10 define Harmful Use?
What is the criteria?
A pattern of substance use that causes damage to health.
The damage may be: (1) physical or (2) mental (This criterion MUST be present if harmful use is diagnosed)
Adverse social consequences
Harmful use includes bingeing on substances. Does not include ‘hangover’ alone
Does not fulfil any other diagnosis within substance use e.g. dependence
In the ICD-10 can you get a diagnosis of dependence syndrome and harmful use?
No, it is one or the other
How does the DSM-5 define opiod use disorder?
How does the DSM-5 define alcohol use disorder?
What is the criteria?
Criteria for opioid and alcohol use disorder are the same:
- Taken longer than intended
- Compulsion for use
- Time taken to acquire substance and recover
- Craving
- Daily life interrupted
- Continued use despite social issues
- Activities reduced due to use
- Use even in hazardous situations
- Continued use despite damaging side effects
- Tolerance
- Withdrawal symptoms
Can be classified as mild (2-3), moderate (4-5) or severe (6+) depending on how many criteria are ticked off
What questions can you ask during history taking to suit Addiction?
Presenting Complaint (PC) History of PC (HPC) Substance Misuse History Family History Past Psychiatric History Social / Personal History
Presenting Complaint (PC) = What is the main issue?
History of PC (HPC) =
How long? Onset? Causes? Signs and symptoms?
Substance Misuse History =
Length of current use? current amount, max use? Method of use? Withdrawals? Previous overdoses? Previous treatments? Triggers for use? Motivation to engage in treatment?
Family History =
FH of mental illnesses or addiction disorders?
Past Psychiatric History =
History of trauma, neglect, abuse? FH of substance misuse / violence? Developmental disorders? Co-morbidities?
Social / Personal History =
Relationshops? Safeguarding concerns? Accommodation / money / debt / employment issues? Forensic history (convictions)?
What are the major causes of morbidity and mortality associated with substance abuse?
Trauma (e.g. fractures) Road Traffic Accidents Homicide Suicide Overdose (deliberate, and frequently accidental)
Cirrhosis (Alcohol) Endocarditis (IV) Abscesses (IV) BBV: Hepatitis B/C & HIV (IV) (ask about vaccinations)
What are some aspects of an assessment specific to opiods?
Examination
Investigations
Examination: Collapsed veins / track marks Endocarditis Skin abscesses Hepatitis / HIV Pneumonia
Investigations: Bloods (LFT, U&E, GGT, Glucose) Breathalyser Urine Drug Screen Sexual health screening/BBV
What do opioids do?
Relieve pain - analgesic effect
Create a sense of euphoria
What is the difference between opiates and opioids?
Opiates = natural opioids e.g. morphine, codeine
Opioids = all natural, semi-synthetic and synthetic opioids
What are different opioids in they natural, synthetic and semi-synthetic forms?
Natural | Synthetic | Semi-synthetic
Opium | Fentanyl | Heroin
Morphine | Pethidine | Hydrocone
Codeine | Methadone | Oxycodone
Thebaine | Tramadol | Hydromorphone
What are the symptoms of opioid overdose?
Unmoving, cannot be woken Slow or no breathing Choking, gurgling, snoring Tiny pupils Clammy / cold skin Cyanosis
How can opioid overdose be treated clinically?
What drug blocks or reverses opioid overuse?
Naloxone - injected into upper arm or thigh / nasal spray
What does a typical community review cover?
Drug / alcohol use Harm reduction Mental health Physical health Social circumstances Recovery support Safeguarding Prescriptions Plan
What are some other illicit substances?
What are some properties of this class of illicit substances?
G-drugs - GHB (gamma hydroxybutyrate) and GBL (gamma butyrolactone) e.g. ecstasy
Mixing G drugs with alcohol can result in death
Small amounts can produce a high, slightly larger amounts can lead to sedation / unconsciousness
Very small difference between smount required for a high VS sedation
Highly addictive
